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MRI of Patellar Disorders     Dr. Bhavin Jankharia      Jankharia Imaging
Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation  and not to miss the diagnosis especially when ...
Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation  and not to miss the diagnosis especially when ...
Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation  and not to miss the diagnosis especially when ...
Acute Injury
PF JointAcute• Dislocation / subluxation• Retinaculum and medial patellofemoral ligament  tears• Chondral lesions
Marrow Edema Anterior Lateral Femoral             Condyle
When marrow edema is seen in the anterior aspect of the lateral femoral condyle, ourantennae need to go up for the presenc...
Here the edema is straightforward….
….as are the associated lateral patellar tilt and subluxation (red arrow) and                  acute chondral defect (yell...
It is when the patella has reduced and the only positive finding is the                       marrow contusion (arrow)
that it becomes necessary to look at the patella and the medialpatellofemoral ligament (MPFL), which is edematous, contuse...
A review of the anterior most STIR coronal images often will show marrow contusion of the medial patellar facet subjacent ...
The MPFL avulsion tear at the patellar attachment is along the inferior aspect(yellow arrow) with involvement of the whole...
Sometimes, the MPFL injury may be a bony avulsion (red arrow)
The MPFL tear can also be at the femoral attachment (red arrow), in whichcase, often the anterior aspect of the femoral at...
Chondral defects (red arrow) may occur due to the shear stress of thesubluxation / dislocation and an effort should be mad...
PF JointAcute Subluxation / Dislocation• Marrow edema of the anterior LFC is a clue
PF JointAcute Subluxation / Dislocation• Marrow edema of the anterior LFC is a clue• If seen, look at the patellar marrow,...
Patellofemoral Incongruence
There are various parameters that    we can use to assess PF incongruence. They are listed in       the next few slides
PF Joint• Measurements  – Patellar lengthpatellar tendon length / patellar bone long   axis length greater than 1.3 usuall...
PF Joint• Measurements  – Patellar length  – Translationgreater than 2 mm difference between the  medial edges is consider...
PF Joint• Measurements – Patellar length – Translation – Abnormal tiltLateral patellar angle less than 8degrees is signifi...
PF Joint• Measurements  – Patellar length  – Translation  – Abnormal tilt  – Trochlear sulcus depth    and lateral femoral...
PF Joint• Measurements  – Patellar length  – Translation  – Abnormal tilt  – Trochlear sulcus depth    and lateral femoral...
PF Joint • Measurements   – Patellar length   – Translation   – Abnormal tilt   – Trochlear sulcus depth     and lateral f...
PF Joint• Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth   and lateral femoral   co...
PF Joint• Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth and lateral femoral condyl...
Old PF Injury
In some patients with PFincongruence, a careful search often reveals evidence of old,  perhaps undiagnosed lateral       p...
This patient has PF incongruence with lateral patellar subluxation and              abnormal tilt with a loose body (red a...
A careful review of the patient in the previous slide shows an old avulsion       injury of the patellar attachment of the...
Chondromalacia
Chondromalacia Patellae• Cartilage softening,  swelling, fibrillation in  young patients• Staging  – Gd 1: softening,    s...
Chondromalacia Patellae• Cartilage softening,  swelling, fibrillation in  young patients• Staging  – Gd 1: softening,    s...
Chondromalacia Patellae• Cartilage softening,  swelling, fibrillation in  young patients• Staging  – Gd 1: softening, swel...
Chondromalacia Patellae• Cartilage softening,  swelling, fibrillation in  young patients• Staging  – Gd 1: softening, swel...
Chondromalacia Patellae• Cartilage softening,  swelling, fibrillation in  young patients• Staging  – Gd 1: softening, swel...
Chondromalacia Patellae• Cartilage softening,  swelling, fibrillation in  young patients• Staging  – Gd 1: softening, swel...
While there is some correlation between PF incongruence andacute lateral patellar subluxation,   repetitive subluxation an...
Dynamic Imaging and Patellar Tracking
As a rule patellar tracking can be doneclinically. The mere demonstration of a tracking abnormality on either static ordyn...
Dynamic Imaging• Patello-femoral joint  – Tracking  – Patellar subluxation and tilt  – Passive, active, with our without l...
Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation  and not to miss the diagnosis especially when ...
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MRI of patellar disorders

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A short presentation on the practical issues related to the patellofemoral joint (subluxation, dislocation and incongruence) and chondromalacia

  • What can be done about Chondromalica pattela. I have a MRI. I have researched that it can be caused by muscular imbalance. How do you know if you have damage or just muscular inbalance causing the pain?
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MRI of patellar disorders

  1. 1. MRI of Patellar Disorders Dr. Bhavin Jankharia Jankharia Imaging
  2. 2. Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation and not to miss the diagnosis especially when the patella has reduced back
  3. 3. Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation and not to miss the diagnosis especially when the patella has reduced back• How to evaluate PF incongruence
  4. 4. Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation and not to miss the diagnosis especially when the patella has reduced back• How to evaluate PF incongruence• Chondromalacia
  5. 5. Acute Injury
  6. 6. PF JointAcute• Dislocation / subluxation• Retinaculum and medial patellofemoral ligament tears• Chondral lesions
  7. 7. Marrow Edema Anterior Lateral Femoral Condyle
  8. 8. When marrow edema is seen in the anterior aspect of the lateral femoral condyle, ourantennae need to go up for the presence of an acute lateral patellar subluxation / dislocation
  9. 9. Here the edema is straightforward….
  10. 10. ….as are the associated lateral patellar tilt and subluxation (red arrow) and acute chondral defect (yellow arrow)
  11. 11. It is when the patella has reduced and the only positive finding is the marrow contusion (arrow)
  12. 12. that it becomes necessary to look at the patella and the medialpatellofemoral ligament (MPFL), which is edematous, contused and torn with subtle lateral patellar translation, best seen on the T2W axial MRI
  13. 13. A review of the anterior most STIR coronal images often will show marrow contusion of the medial patellar facet subjacent to the attachment of the MPFL
  14. 14. The MPFL avulsion tear at the patellar attachment is along the inferior aspect(yellow arrow) with involvement of the whole MPFL up to the anterior femoral attachment of the medial collateral ligament (MCL) (blue arrow). Note the marrow contusion in the anterior LFC (red arrow).
  15. 15. Sometimes, the MPFL injury may be a bony avulsion (red arrow)
  16. 16. The MPFL tear can also be at the femoral attachment (red arrow), in whichcase, often the anterior aspect of the femoral attachment of the MCL (blue arrow) may be involved.
  17. 17. Chondral defects (red arrow) may occur due to the shear stress of thesubluxation / dislocation and an effort should be made to look for additional cartilage fragments (blue arrow)
  18. 18. PF JointAcute Subluxation / Dislocation• Marrow edema of the anterior LFC is a clue
  19. 19. PF JointAcute Subluxation / Dislocation• Marrow edema of the anterior LFC is a clue• If seen, look at the patellar marrow, cartilage, MPFL and congruence
  20. 20. Patellofemoral Incongruence
  21. 21. There are various parameters that we can use to assess PF incongruence. They are listed in the next few slides
  22. 22. PF Joint• Measurements – Patellar lengthpatellar tendon length / patellar bone long axis length greater than 1.3 usually suggests patella alta Chhabra et al. Skeletal Radiol (2011) 40:375 387
  23. 23. PF Joint• Measurements – Patellar length – Translationgreater than 2 mm difference between the medial edges is considered significant Chhabra et al. Skeletal Radiol (2011) 40:375 387
  24. 24. PF Joint• Measurements – Patellar length – Translation – Abnormal tiltLateral patellar angle less than 8degrees is significant. The angle should open laterally. Chhabra et al. Skeletal Radiol (2011) 40:375 387
  25. 25. PF Joint• Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth and lateral femoral condylar overgrowth Trochlear depth of 3mm or less andtrochlear angle greater than 145 degreessuggests trochear dysplasia / hypoplasia Chhabra et al. Skeletal Radiol (2011) 40:375 387
  26. 26. PF Joint• Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth and lateral femoral condylar overgrowthLateral femoral condylar protrusion greater than 8 mm suggests overgrowth
  27. 27. PF Joint • Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth and lateral femoral condylar overgrowth – Tibial tubercle - trochlear groove distanceDistance greater than 15mm suggests an abnormal TT-TG distance Chhabra et al. Skeletal Radiol (2011) 40:375 387
  28. 28. PF Joint• Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth and lateral femoral condylar overgrowth – Tibial tubercle - trochlear groove distance Chhabra et al. Skeletal Radiol (2011) 40:375 387
  29. 29. PF Joint• Measurements – Patellar length – Translation – Abnormal tilt – Trochlear sulcus depth and lateral femoral condylar overgrowth – Tibial tubercle - trochlear groove distance – Superolateral Hoffas fat pad signal, etc Chhabra et al. Skeletal Radiol (2011) 40:375 387
  30. 30. Old PF Injury
  31. 31. In some patients with PFincongruence, a careful search often reveals evidence of old, perhaps undiagnosed lateral patellar subluxation
  32. 32. This patient has PF incongruence with lateral patellar subluxation and abnormal tilt with a loose body (red arrow)
  33. 33. A careful review of the patient in the previous slide shows an old avulsion injury of the patellar attachment of the MPFL (red arrows)
  34. 34. Chondromalacia
  35. 35. Chondromalacia Patellae• Cartilage softening, swelling, fibrillation in young patients• Staging – Gd 1: softening, swelling Elias DA. Clin Radiol 2004; : 543
  36. 36. Chondromalacia Patellae• Cartilage softening, swelling, fibrillation in young patients• Staging – Gd 1: softening, swelling – Gd 2: fragmentation, fissuring upto 1.3mm Elias DA. Clin Radiol 2004; : 543
  37. 37. Chondromalacia Patellae• Cartilage softening, swelling, fibrillation in young patients• Staging – Gd 1: softening, swelling – Gd 2: fragmentation, fissuring upto 1.3mm – Gd 3: fissuring > 1.3mm Elias DA. Clin Radiol 2004; : 543
  38. 38. Chondromalacia Patellae• Cartilage softening, swelling, fibrillation in young patients• Staging – Gd 1: softening, swelling – Gd 2: fragmentation, fissuring upto 1.3mm – Gd 3: fissuring > 1.3mm Elias DA. Clin Radiol 2004; : 543
  39. 39. Chondromalacia Patellae• Cartilage softening, swelling, fibrillation in young patients• Staging – Gd 1: softening, swelling – Gd 2: fragmentation, fissuring upto 1.3mm – Gd 3: fissuring > 1.3mm – Gd 4: cartilage loss down to subchondral bone Elias DA. Clin Radiol 2004; : 543
  40. 40. Chondromalacia Patellae• Cartilage softening, swelling, fibrillation in young patients• Staging – Gd 1: softening, swelling – Gd 2: fragmentation, fissuring upto 1.3mm – Gd 3: fissuring > 1.3mm – Gd 4: cartilage loss down to subchondral bone Elias DA. Clin Radiol 2004; : 543
  41. 41. While there is some correlation between PF incongruence andacute lateral patellar subluxation, repetitive subluxation and chondromalacia, each of these can exist without the other
  42. 42. Dynamic Imaging and Patellar Tracking
  43. 43. As a rule patellar tracking can be doneclinically. The mere demonstration of a tracking abnormality on either static ordynamic real-time images is usually not clinically relevant
  44. 44. Dynamic Imaging• Patello-femoral joint – Tracking – Patellar subluxation and tilt – Passive, active, with our without loading
  45. 45. Patellar DisodersPF Joint• How to diagnose acute subluxation / dislocation and not to miss the diagnosis especially when the patella has reduced back• How to evaluate PF incongruence• Chondromalacia
  46. 46. Thank You

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